During morning care, unlicensed assistive personnel observe a ...

[TVarnum]

During morning care, unlicensed assistive personnel observe a client's abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel do?
 
  1. Reinforce the wound with supplies on the client's bedside table.
  2. Document that the bath was completed, and the condition of the dressing.
  3. Complete the bath, then report the change to the nurse.
  4. Report the dressing changes to the nurse immediately.

Question 2

The nurse is preparing to irrigate a client's abdominal wound. In which order should the nurse perform this irrigation?
 
  1. Dry the area around the wound.
  2. Insert the catheter into the wound until resistance is met.
  3. Remove and discard clean gloves.
  4. Apply clean gloves.
  5. Irrigate until the solution flows clear.
  6. Select a syringe with a catheter attached or with an irrigating tip.

[nicoleclaire22]

Answer to Question 1

Correct Answer: 4
Rationale 1: UAP are not trained to reinforce dressings. This should not be done.
Rationale 2: UAP should not document that the bath was completed before communicating the dressing changes to the nurse.
Rationale 3: UAP should not complete the bath first.
Rationale 4: When delegating the care of the client to the UAP, the nurse should have provided direction to the UAP to report any changes to the nurse. UAP should report the dressing changes to the nurse immediately.

Answer to Question 2

Correct Answer: 4,6,2,5,1,3
Rationale 1: After irrigating, the nurse should dry the area around the wound.
Rationale 2: The nurse should then insert the catheter into the wound until resistance is met.
Rationale 3: The nurse should then remove and discard the clean gloves.
Rationale 4: The nurse first should apply clean gloves.
Rationale 5: The nurse should then irrigate the wound until the solution flows clear.
Rationale 6: The nurse should then select a syringe with a catheter attached or with an irrigating tip.

[TVarnum]

TYSM

Gracias!